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Keeping up with education and training with The Joint Commission and CMS

Keeping up with education and training with The Joint Commission and CMS

Editor’s note: The following article was written by healthcare consultants Marlene Strader, PhD, RN, and BOJ advisor Elizabeth Di Giacomo-Geffers, RN, MPH, CSHA. Both are former surveyors for The Joint Commission. 

Education and training for hospital staff has always been time-consuming and costly for both organizations and personnel. When hospitals develop education and training for staff, they must make sure programs improve clinical practice and keep them updated regarding changes that occur in the healthcare, technology, and clinical practice.  

In the past 15 years, educational requirements set out by The Joint Commission, and more recently CMS, have added to the burden hospitals have in providing education and training to staff. 

In addition, the Human Resources chapter in the Comprehensive Accreditation Manual for Hospitals (CAMH) also requires job descriptions, background checks (if required by law), primary source verification of licensure, orientation, competence assessments, and performance evaluations.  

Initially, prior to electronic versions of the various Joint Commission manuals, hospital staff members who were involved in planning educational programs relied on the most obvious methods to gather information for required education. Reviewing the Human Resources chapter, standards, networking with other hospitals, triennial surveys, and consultants were the preferred means for determining the Joint Commission educational requirements. 

Over time, however, education and training moved beyond the Human Resources chapter to be included in various other chapters. The list of requirements also grew as well as the expansion of the definition of “staff” and inclusion of licensed independent practitioners (LIP) for specific education topics.  

Hospitals now had to comply with requirements in the Human Resources chapter, as well as the endless list of education and training topics in other chapters. Who, how frequent, and what were questions HR and educational staff were asking.

Electronic manuals

When the electronic versions of the various Joint Commission manuals were created, it seemed like a good idea to use the features of the PDF software to find where in all of the standards education was mentioned. What started out as the “Competence Assessment Process Review Request Form” way back in the early 90s became the basis for the tool developed by the authors.  

The Human Resources chapter, specifically the standard addressing education and training, identifies various topics, such as population served, team communication, coordination of care, reporting unanticipated adverse events, fall reduction program, and early warning signs of change in patients’ conditions. Education required at orientation is also included in this chapter—for example, cultural diversity, patient rights, and forensic restraint. 

For many years, hospital staff and surveyors were content to view the topics in the Human Resources chapter as the only ones required, but slowly education was introduced in other chapters, and surveyors, when reviewing personnel files, began to notice the chapter was not quite up to date. Thus, the authors began to search all chapters in the CAMH manual. There are approximately 28 topics listed that require staff education at orientation or at a frequency determined by the hospital.  

Although physicians are not included in the Human Resources chapter, there are educational requirements in other chapters that affect physicians as well as other patient care providers. Education requirements for physicians include “reporting safety concerns to The Joint Commission,” “fire safety,” “pain management,” “early warning signs in change of patient’s condition,” “influenza,” “prevention strategies for multidrug-resistant organisms (MDRO),” and “impairment of LIPs.”  

The most difficult issue for organizations regarding physician education is demonstrating that education was provided and received by physicians. One particular problem is the CMS requirement §482.13(f)(2)(i) that at a minimum, physicians and other LIPs authorized to order restraint or seclusion by hospital policy in accordance with state law must have a working knowledge of hospital policy regarding the use of restraint and seclusion. The Interpretive Guidelines from CMS direct the surveyor to review physician credential files to determine compliance.

Frequency of education

Frequency of education is also a challenge. The addition of so many topics to cover by The Joint Commission and CMS made the list longer each year.  

It is important for hospitals to make a decision as to the frequency of education that will be provided to staff on the various topics. There are only a few topics that require annual education and/or training: MDRO, central line–associated bloodstream infections (CLABSI), surgical site infections (SSI), and waived testing. Education and training on the use of restraint, and MDRO, CLABSI, and SSI must also be provided at the time of hire.  

Restraint education should be provided on a periodic basis thereafter. The Joint Commission permits organizations to determine the time frame for ongoing education, but it is implied that it should occur no less than every three years. State laws may differ. 

What are the most effective methods of providing education and training? Most hospitals develop some type of computer-based training module. Although this method is probably the simplest to provide, not all education and training should be conducted in this manner.  

An effective education and training program should be divided into thirds. One-third is for didactic training, one-third is for direct observation, and one-third is for simulation.  

However, education programs provided by hospitals should be evaluated regularly because they are expensive and need to be modified or discontinued if they are not effective. This evaluation does not always happen in the majority of hospitals.

Finally, exactly who is required to obtain the necessary education? The hospital does have the ability to determine the “who.” However, it will take some thought-provoking decision-making to accurately identify those patient care providers who should receive education and/or training about the topic.  

For example, should a dietitian be required to have education about pain management? It depends. If the dietitian is performing a nutritional assessment on a patient with head/neck cancer, it would be critical to understand the patient’s perception of pain with swallowing and chewing and what tolerance is acceptable. On the other hand, a nurse in primary care would not necessarily be required to have education regarding sensitivity and discretion regarding organ donation. It is important that a thorough assessment of the needs of the staff take place to make sure the appropriate personnel receive the necessary education.

Refer to the sidebar on p. 10 for a snapshot of required education and training, contributing standards, frequency, and personnel. A complete version is available online at 

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